Circumferential wound retraction with support and guidance structures

ABSTRACT

Embodiments of a circumferential retractor having an attached supporting, manipulating or positioning tool are described. The retractor optionally includes a sealing member associated with an external member of the retractor and an external support structure that may be used with the retractor and positioning tool as needed.

CROSS REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of U.S. Provisional Application Ser. No. 62/084,435 entitled “CIRCUMFERENTIAL WOUND RETRACTION WITH SUPPORT AND GUIDANCE STRUCTURES,” filed Nov. 25, 2014.

FIELD OF THE INVENTION

The present invention relates to retraction of surgical incisions and other orifices, and more specifically to shaping and positioning a surgical incision or orifice to provide optimum access to a surgical site.

BACKGROUND

Generally speaking, the considerations involved in providing a surgical incision include adequate access to a subject area within the anatomy, minimal blood loss, maximum closure and healing potential, and minimal scaring.

Several elegant surgical incision techniques have been developed to address the foregoing. For instance the “Phannenstiel” incision used in abdominal surgery was developed to minimize the development of surgical site herniations.

With the advent of laparoscopic surgery, it has become apparent that small incisions have certain advantages. However, some surgeries present challenges that are beyond standard laparoscopic or totally open techniques. One of these is human breast surgery. In these instances, access is very important. However, aesthetic outcome is almost equally important.

Typical human breast surgery generally comprises either a periareolar incision or an inframammary incision or both. Other, more complex incision types are also available for various specific needs. For instance a triangular incision may be used where mass reduction is provided. A vertical incision may be used where maximum access is desired. Alternatively, a “b-flap” incision may be employed where specific reconstruction is indicated. This is an incision that extends from the vertical incision site to a selected lateral position. In some cases an incision is made in the umbilicus and access to breast is provided beneath the skin level.

Generally, opposing mechanical retractors are used to spread, open or enlarge an incision for appropriate access. The mechanical retractors may be moved in tandem to position the incision to maximize access and visualization. This action requires complicated and orchestrated action, usually involving two operators. An additional complication may arise when metallic retractors are employed in an environment where electrosurgical devices are in use. The potential for unintended electrical discharge is clearly present. This could result in burns that are difficult to anticipate and manage.

In view of the foregoing, there remains a need to provide surgical access to the human breast and other areas of the human body that provides acceptable access and further provides exceptional cosmetic outcome but which avoids the complications and risks of mechanical retractors.

BRIEF DESCRIPTION OF THE INVENTION

The present invention provides surgical retractor for use in a surgical incision or at a natural orifice, comprising an external support member; an internal support member; a connecting member having a distal end, a proximal end, and a tissue contacting surface, the proximal end of the connecting member connected to the external support member and the distal end of the connecting member connected to the internal support member; and a first positioning element comprising a holding portion and a connecting portion, wherein the connecting portion is attached to the external support member. In some embodiments, the connecting portion comprises a recess configured to complement the external support member such that the connecting portion may be snap fit onto the external support member to thereby attach the positioning element to the external support member. In other embodiments, the positioning element comprises a connecting feature configured such that the connecting feature may be urged over and about the external support member to thereby attach the positioning element to the external support member. In still other embodiments, the positioning element comprises a cut-out area and defines an opening sized and configured to slide past the connecting member so that the cut-out area may engage the external support member to thereby attach the positioning element to the external support member.

Optionally, the surgical retractor further comprises a support structure, the support structure having a base and a pivot point, wherein the base is configured to attach to a surgical table and the pivot point is configured to attach to the holding portion of the positioning element.

In some embodiments, a second positioning element may attached to the external support member. Optionally, the surgical retractor may also comprise a first support structure and a second support structure, each support structure having a base and a pivot point, wherein the bases are configured to attach to a surgical table, the pivot point of the first support structure is attached to the first positioning element and the pivot point of the second support structure is attached to the second positioning element.

In some embodiments, the internal support member comprises an inflatable toroid, the inflatable toroid being connected to a transfer conduit configured to interact with a gas or fluid supply. In other embodiments, the internal support member comprises a memory foam, the internal support member configured to be deformed for insertion through an incision, returning to a predetermined shape once within the surgical field.

In other embodiments, the surgical retractor comprises an external support member; an internal support member; a connecting member having a distal end, a proximal end, and a tissue contacting surface, the proximal end of the connecting member connected to the external support member and the distal end of the connecting member connected to the internal support member; a seal cap, the seal cap comprising a cap ring and an elastomeric seal disposed within the cap ring, wherein the cap ring is configured to sealingly engage the external support member, the cap ring comprising an attachment feature; and a first positioning element comprising a holding portion and a connecting portion, wherein the connecting portion is configured to detachably engage with the attachment feature. Optionally, the attachment feature comprises a series of tabs and grooves configured to form a complementary fit with the connecting portion of the positioning element. In some embodiments, a second positioning element may be configured to detachably engage with the attachment feature.

In some embodiments, the elastomeric seal comprises at least one access port. In other embodiments, the elastomeric seal further comprises at least one receptacle and at least one insert configured to fit in the receptacle.

In some embodiments, a surgical retractor comprises an external support member; an internal support member; a connecting member having a distal end, a proximal end, and a tissue contacting surface, the proximal end of the connecting member connected to the external support member and the distal end of the connecting member connected to the internal support member; and an external support structure, wherein the external support structure comprises an adjustable neck attached to a table stand, the adjustable neck configured to detachably attach to the external support member. Optionally, the adjustable neck comprises a first arm segment, a second arm segment and a hinge, the hinge connecting the first arm segment and the second arm segment.

In one embodiment useful when insufflating cavities within the body, the retractor comprises an external support member; an internal support member; a connecting member having a distal end, a proximal end, and a tissue contacting surface, the proximal end of the connecting member connected to the external support member and the distal end of the connecting member connected to the internal support member; a pressure sensitive seal, the seal comprising a cylindrical body, a movable sealing member, a compression spring disposed within the cylindrical body, the compression spring configured to engage the movable sealing member, and a cap having at least one opening, the cylindrical body comprising a first open end configured to attach to the external support member, a second open end attached to the cap, a first portion positioned near the first open end, the first portion having a smooth interior surface, and a second portion positioned near the second open end, the second portion having a fenestrated interior surface, wherein the opening in the cap is aligned with at least one fenestration and the sealing member is configured to move within the cylindrical body in response to pressure changes, from a low pressure state in which the sealing member is positioned within the first portion to sealing engage the smooth interior surface to a high pressure state in which the sealing member is forced upward by insufflation gases against the compression spring into the second portion having a fenestrated interior surface, thereby allowing the insufflation gas to escape through the opening in the cap and returning the sealing member to the low pressure state. Optionally, the cap is axially or radially adjustable to modulate the pressure of the insufflation gas. In still another embodiment of the present invention, the surgical retractor is illuminated, comprising an external support member; an internal support member; a connecting member having a distal end, a proximal end, and a tissue contacting surface, the proximal end of the connecting member connected to the external support member and the distal end of the connecting member connected to the internal support member; a positioning element comprising a holding portion and a connecting portion, wherein the connecting portion is attached to the external support member; and an illumination element attached to the internal support member. In some embodiments, the illumination element comprises a flexible fiber-optic bundle disposed within a tubular structure and connected to a light source by a fiber option cable. In other embodiments, the illumination element comprises light emitting diodes (“LEDs”) disposed with a tubular ring, the LEDs connected to an energy source by an electrical conduit.

Optionally, the illuminated element is attachable to and detachable from the interior support member. In some embodiments, the illuminated surgical retractor comprises a reflective surface on the illumination element, configured to reflect light into the surgical field.

These and other features of the invention will become more apparent with a discussion of the various embodiments in reference to the associated drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 illustrates a first use of a circumferential retractor involving a human breast in a periareolar incision.

FIG. 2 is a lateral view of a transaxillary incision where a circumferential retractor is placed within said incision.

FIG. 3 is a perspective view of a circumferential retractor.

FIG. 4A is a top view of a circumferential retractor with an attached positioning or manipulating element, deployed in a periareolar incision.

FIG. 4B is a top view of a circumferential retractor with an attached positioning or manipulating element, deployed in a transaxillary incision.

FIG. 5A is a perspective view of a positioning element adapted to snap over an outer ring.

FIG. 5B is a perspective view of a connecting feature adapted to attach to an external support structure.

FIG. 5C is a perspective view of a positioning element with a cut-out area configured to engage an external support member.

FIG. 6A is a lateral view of a transaxillary incision where a circumferential retractor is placed within said incision and a positioning member is attached and maneuvered to first preferred position.

FIG. 6B is a lateral view of a transaxillary incision where a circumferential retractor is placed within said incision and a positioning member is attached and maneuvered to a second position.

FIG. 7 illustrates the circumferential retractor of FIG. 4A with a second attached positioning or manipulating element.

FIG. 8A is a perspective view of a retractor having a first and a second positioning element with the first positioning element placed under an external support structure.

FIG. 8B is a perspective view of a retractor having a first and a second positioning element, with the second positioning element comprising an engaging feature adapted to attach to the first positioning element.

FIG. 8C is a perspective view of a retractor having a first and a second positioning element, with the second positioning element configured to attach to an open connecting portion of the first positioning element.

FIG. 8D is a perspective view of a retractor having a first and a second positioning element, with the first and second positioning elements configured to slide past the cylindrical connecting member to upwardly engage an external support member.

FIG. 9 is a lateral view of a transaxillary incision illustrating the use of more than one positioning element.

FIG. 10 is a lateral view of a transaxillary incision illustrating the use of more than one positioning element and a stabilizing member.

FIG. 11 is a perspective top view of a circumferential retractor having two positioning members and a seal cap.

FIG. 12 is a side-section view of the circumferential retractor of FIG. 11.

FIG. 13 is an oblique side-section view of the circumferential retractor of FIG. 11, which the elastomeric seal portion removed.

FIG. 14 is a perspective top view of a circumferential retractor having two positioning members and a seal cap with dedicated instrument seals.

FIG. 15 is a perspective bottom view of a circumferential retractor having two positioning members and a seal cap with dedicated instrument seals.

FIG. 16 is an oblique top view of a seal cap according to one aspect of the present invention where flat instruments may be used.

FIG. 17A is a top-side detailed view of a seal cap having various individual access ports.

FIG. 17B is a bottom-side detailed view of the seal cap of FIG. 17A.

FIG. 18 illustrates a circumferential retractor having a seal-cap and a plurality of removable or exchangeable access port inserts.

FIG. 19 is an oblique view of an embodiment of a circumferential retractor having a tapered connecting member or sleeve.

FIG. 20 is a perspective view of a circumferential retractor having an inflatable inner support member, shown in a first, uninflated condition (solid) and a second, inflated condition (broken).

FIG. 21A illustrates a foldable inner support member of a circumferential retractor, having a disk-shaped inner support member shown in the folded position.

FIG. 21B illustrates the foldable inner support member of FIG. 21A, shown in an unfolded position.

FIG. 21C illustrates a ring-shaped inner support member.

FIG. 22A shows a lateral view of a support member associated with a circumferential retractor, before manipulating the support member to increase the surgical field.

FIG. 22B shows a lateral view of a support member associated with a circumferential retractor, after manipulating the support member to increase the surgical field.

FIG. 23 illustrates the use of a hinged, pivoted support element attached to a circumferential retractor.

FIG. 24 illustrates the use of a dissecting tool having a gas or fluid supply.

FIG. 25 is a side section view of a relief valve for use with a sealed circumferential retractor.

FIG. 26 is an oblique section view of a relief valve for use with a sealed circumferential retractor.

FIG. 27 illustrates the use of an illuminating instrument.

FIG. 28 illustrates a circumferential insufflating retractor having a seal-cap and an illuminating element.

FIG. 29 is an enlarged oblique bottom-side view of a circumferential retractor having an integrated illuminating element.

FIG. 30 is an exploded oblique bottom-side view of a circumferential retractor having a detachable illuminating element.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

The present invention describes a circumferential incision retractor or wound retractor and a supporting, manipulating or positioning tool that detachably attaches to the circumferential retractor. Optionally, a sealing member associated with an external member of the retractor and/or an external support structure may be used with the manipulating tool or member as needed. The disclosed embodiments are described with reference to their use in human breast surgery, although they may be used as appropriate in other surgical procedures, particularly where cosmetic outcome is important. It should also be appreciated that the described retractor may also be used in natural orifices where appropriate.

FIG. 1 shows a female human torso 10 in a supine position with a periareolar skin incision 31 made in the breast 11 to gain access to the interior tissue. A circumferential retractor 71 according to the present invention is placed within the incision 31 and deployed to reshape and shield the initial incision as desired. The circumferential retractor acts on the initial incision to produce an enlarged opening 39 through which surgical instruments may be inserted. Deployment of a circular retractor 71 in a transaxillary incision is shown in FIG. 2.

Surgical instruments may be inserted and used through the retractor 71 and the modified incision 31 as desired. In a preferred embodiment, shown in FIG. 3, the circumferential retractor 71 comprises a first, internal support member 155, a second, external support member 153 and a cylindrical connecting member 154. The connecting member 154 comprises an external tissue-contacting surface and an internal surface that, when deployed, lines an access opening into the body. The connecting member 154 is preferably sized and configured to present a circumferential outward force or pressure upon tissue through which it has been inserted as it is acted upon by activity associated with an external support member 153. More simply stated, as the external support member 153 is rotated upon itself, the attached connecting member 154 is shortened linearly. As the connecting member 154 is shortened, the tissue through which it has been inserted is forced away from the axis of the device 71. The result of the force upon the tissue is an enlarged opening 39 through which a surgical procedure may be performed.

It should be noted that the particular configuration of the internal and external support members may be varied depending on particular use. For example, the support members are shown as circular rings but may have other shapes, such as oval or semicircular. Also, the support members may occur singly or in some multiple as, for example, a double-ring external support member. The support members may be solid or hollow, flexible or rigid. Suitable circumferential retractors are described in U.S. Pat. Nos. 7,650,887, 7,727,146 and 7,704,207, the disclosures of which are incorporated by reference in their entireties.

In FIG. 4A, a female human torso 10 is shown with a periareolar incision 31 in the breast 11, into which a circumferential retractor 71 has been placed to create an enlarged opening 39. Once the circumferential retractor 71 is appropriately placed, a first positioning element 90 may be placed upon the external support member 153 and used to maneuver the retractor 71 as desired. The first positioning 90 may preferably comprise a connecting portion 92 and a holding portion 94. The connecting portion 92 may be sized and configured to attach to the external support member 153 in a way that it can be rotated about the central axis of the device 71. The positioning element 90 may additionally be configured to be held by a human hand 110. In FIG. 4B, a female human torso 10 is shown with a transaxillary incision 42 in the breast 11, into which a circumferential retractor 71 with a positioning element 90 has been placed to create an enlarged opening 39.

In a preferred embodiment, a positioning element 90 associated with the retractor 71 of the present invention may be rotated 360 degrees around the central axis of the circumferential retractor 71 without presenting rotational forces upon the associated tissue. The positioning element 90, once attached to the external support member 153, may be used to maneuver or position the retractor 71 to a preferred orientation or position.

With reference to FIGS. 5A-5C, one or more positioning elements 90, 91 may be attached to the external support member 153 in a variety of ways. A first positioning element 90 may be snapped over the outer ring or external support structure 153 so that the structure is contained within an undercut in the connecting portion 92 that allows axial rotation of the handle 90 about the axis of the circumferential retractor (FIG. 5A). An alternate embodiment, shown in FIG. 5B, makes use of at least one connecting feature 394 positioned on the connecting portion 92 that may be urged over and about the external support structure 153. An additional embodiment makes use of a positioner 90 having a connecting portion 393 with an opening 396 sized and configured to slide past the cylindrical connecting member 154 and then upward so that a cut-out area 395 of the connecting portion 393 may engage the external support member 153 (FIG. 5C).

With a positioning element attached to the circumferential retractor, an operator may manipulate the incision or wound from its initial position to a first preferred position or a second preferred position depending on the particular surgical needs. Performing such manipulation with the present invention reduces trauma to the incision site than conventional mechanical retractors and provides a more open operative space.

FIG. 6 shows a lateral view of a transaxillary incision 43 where a circumferential retractor 71 is placed within said incision and a positioning member 90 is attached and maneuvered to first preferred position (FIG. 6A, shown with broken lines) and to a second preferred position (FIG. 6B, shown with broken lines). A second operative hand 111 is free to deploy medical instruments (not shown) through the enlarged opening 39 at any of the positions.

In a further preferred embodiment, shown in FIG. 7, a second positioning element 91 may be attached to the external support member 153 in a similar manner as the first positioning element 90. The thusly attached positioning elements 90, 91 may be rotated independently about the central axis of the circumferential retractor 71.

Referring now to FIGS. 8A-8C, one embodiment of a scheme to attach two positioning elements to the external support structure 153 comprises a first positioning element 90 having an open connecting portion 393 placed under the external support structure 153 (FIG. 8A) and a second positioning element 91 that may be attached to the first positioning element 90 thereby capturing the external support structure 153 for maneuvering. A preferred embodiment of the second positioning element 91 comprises one or more engaging features associated with the underside 97 of the generally circular connecting portion 92 of the positioning element 91 (FIG. 8B), sized and configured to attach to the open connecting portion 393 of the first positioning element 90 (FIG. 8C). Engaging features may include, for example, tabs and detents, hooks and lattices, and the like.

Any combination of the embodiments shown in FIG. 5 may also be used to attach two positioning elements 90, 91 to the external support structure 153. For example, the first positioning element 90 may be snapped over the external support member 153 as in FIG. 5A, while the second positioning element 91 may include a connecting portion 393 configured to attach as shown in FIG. 5C. In FIG. 8D, both positioning elements attach by sliding past the cylindrical connecting member 154 and upward to engage the external support member and/or the other positioning element.

Referring to FIGS. 9 and 10, a preferred embodiment may comprise a first positioning element 90 that may be held with one hand 110 of a first operative individual and a second positioning element 91 that may be held with one hand 111 of a second operative individual. The cooperative action of the two associated positioning elements 90, 91 allows extreme manipulation of the retractor 71. In an alternate preferred embodiment, a first 90 or second 91 positioning element may attach to a support structure 93 associated with a surgical platform such as an operating table. In this instance, the attachment of a positioning element provides a pivot point 96 or fulcrum so that manipulation and positioning of the retractor 71 may be accomplished by a single hand. A second support structure may be employed to attach to either a first or second positioning element 90, 91 so that an associated retractor may be positioned and held in place as desired. It is important to note that while the present device is depicted for use in the axillary region 43, it may be used in other surgical site locations as well.

A preferred embodiment of the present invention, shown in FIGS. 11-15, may further comprise an external attachment member or seal cap 157 that is sized and configured to provide a gas-tight seal at the outer, external, proximal portion of the retractor 71. The gas-tight seal allows positive pressurization of an anatomical region associated with the distal or internal portion of the circumferential retractor 71. A preferred gas-tight seal cap 157 may comprise a cylindrical elastomeric member sized and configured to fit securely upon an external support member 153 associated with a circumferential retractor 71.

For example, as seen in FIGS. 11-12, an elastomeric seal member or cap 157 according to the present invention comprises a disk-shaped portion 161 having a diameter, a thickness, a first surface 158, a second surface 159 and cap ring 162 configured to hold the disk-shaped elastomeric seal portion. Preferably, the cap ring further comprises an attachment feature 156. Attachment feature 156 may be configured to detachably interact with the connecting portion 92 of one or more positioning elements 90, 91. For example, the attachment feature may be a series of alternating tabs and grooves which form a complementary fit with the connecting portion.

FIG. 13 shows the retractor plus seal cap of FIG. 12 in oblique view, with the disk-shaped portion removed to show a circumferential ledge 163, which supports the disk-shaped elastomeric seal member within the cap ring 162. As shown in FIG. 13, the cap ring attaches to the external support member 153 of the retractor.

In a preferred embodiment, the elastomeric seal member 157 is highly flexible or, at least, made from a soft, compliant material such as styrene-block-copolymer or silicone rubber. In a first embodiment, a surgical tool or instrument may be passed through the material and into a body cavity. In a second embodiment, a surgical tool or instrument may be passed through an access port 167 associated with the elastomeric seal member 157 and into a body cavity.

The elastomeric member or cap 157 may additionally be configured to accept the passage of surgical tools or instruments while preventing depressurization of an internal area, as shown in FIGS. 14-15. The elastomeric seal member 157 may further comprise one or more individual sealing access ports 167. Each of the individual access ports may further comprise a septum 168 and a check valve 169. The individual access ports 167 may be sized and configured to respond to surgical tools or instruments within a range of nominal sizes.

For purposes of construction, the individual access ports 167 associated with the elastomeric seal 157 member may be integrally formed. The present invention contemplates that the individual access ports 167 may be sized and configured for larger or smaller instruments according to the demands of a specific procedure. In addition, a specific procedure may call for an irregularly shaped instrument. Therefore, the elastomeric seal member 157 and individual access ports 167 may be adapted or manufactured to accommodate the tools, devices or instruments associated with a specific procedure. For instance, an elastomeric seal member 157 designed for use in breast surgery may comprise two or more access ports 167 sized and configured for surgical instruments having a five millimeter shaft-diameter. In addition, one port may accommodate a telescope having a shaft diameter of eight millimeters or more or less. In addition to the foregoing, an additional access port 160, 164 may be sized and configured to accommodate a generally flat-shaped instrument, such as a dissecting probe or otherwise spatulated instrument, as shown in FIGS. 16 and 17A,B.

Now referring to FIG. 18, an alternate construction according to the present invention comprises one or more individual access ports 167 that are exchangeable according to the procedural needs of a specific surgery. For instance, a small-bore insert 222 may be placed within the elastomeric seal cap 157 as needed. Next, an insert 223 having a larger bore may be placed as needed. An additional insert 221 having different characteristics than the first two inserts may be placed. In other words, the present invention contemplates a variety of individual seal inserts that may be selected as required and placed within receptacles 220 within the seal cap 157.

As discussed above, the present invention may be used in a variety of surgical scenarios, although it does have particular use in breast surgery. Some surgical procedures, including breast surgery, may require considerable lateral retraction while still keeping the incision as small as possible. Also, some surgical sites may have limited space in which to anchor the internal support structure, a situation very different from abdominal surgery, for example. In such instances, a preferred embodiment of the present invention further comprises an internal support structure that may be significantly smaller than the outer support structure, as seen in FIG. 19. In this embodiment, the connecting member 174 is frustoconical in shape, connecting a smaller internal support member 171 to a larger external support member 170.

Referring now to FIG. 20, an inflatable distal or inner support member 180 is shown comprising a hollow toroidal shaped distal or internal member. The distal retention member 180 is sized and configured to be insert-able through a small surgical incision and subsequently pressurized or inflated to achieve a preferred shape and size 180′ that may not otherwise be insertable through the incision. A preferred embodiment may include an inflatable toroidal retention member 180 that is pressurized by gas or fluid by means of a gas or fluid supply associated with a transfer conduit 181. The unpressurized internal support member 180 may be easily placed through a small surgical incision and subsequently expanded, pressurized or filled to achieve preferred size or rigidity. A preferred embodiment of the inflatable member comprises a toroidal support element having a supply conduit that may be further connected to a syringe 182 having a preferred volume for gas or fluid. The inflatable member may be deflated at anytime for easy retrieval from the surgical incision.

A further embodiment of an expandable inner support member may comprise a toroidal-shaped, disk-shaped 176 or ring-shaped 177 inner member constructed from “memory-foam”. A preferred embodiment of memory foam may include the use of “viscoelastic” polyurethane foam. The viscoelastic foam element may be deformed by hand or by packaging, inserted through a surgical incision and subsequently allowed to return to a predetermined shape and size once within the surgical site. Embodiments of this design are shown in FIG. 21.

Referring to FIGS. 4, 6, 7, 9, 10, 22 and 23, the present invention contemplates several methods for creating operative space within an anatomical region. Using, as an example, a human breast 11, a first method for creating operative space may comprise: placing a circumferential retractor 71 within an incision, attaching at least a first manipulating or positioning element 90 upon a placed retractor 71 and maneuvering said positioning element 90 so as to create a working environment.

A second method for creating operative space may comprise: placing a circumferential retractor 71 within an incision, attaching a proximal or external seal member or cap 157 and supplying an insufflation gas to the associated body cavity. An additional method for creating operative space may further comprise a combination of the two previously described methods.

A further method for developing and maintaining an operative space, shown in FIG. 22, may include the use of an adjustable external support structures 200. For example, an adjustable structure may comprise a semi-flexible “goose-neck” type element 202 that provides sufficient support to prevent collapse of the surgical field 250. The adjustable structure detachably connects to the external support member 153 of the circumferential retractor 71 at a proximal end; the distal end comprises a table stand 201 that may be affixed to the operative table. As shown in FIG. 22A, after the circumferential retractor 71 is placed at the desired surgical site, the support structure 200 is attached to the external support member 153. The adjustable neck portion 202 of the structure 200 may be positionable by hand to, for example, raise the circumferential retractor 71, and thus the breast, to thereby expand the surgical field 250 (FIG. 22B). While adjustable, the neck does have sufficient stiffness to remain as positioned as the surgery continues.

A more robust support structure, shown in FIG. 23, may comprise a hinged or pivoted arm 275. The pivot-points 274 a-d may further comprise tensioning controls that maintain individual arm segments 275, 276, 277 as positioned. A preferred embodiment of the foregoing contemplates that the support structures 200, 275 may be attached to an operative table 273 or a stand. In FIG. 23, the breast 11 is shown in a first, unexpanded state 12, with the corresponding position of the hinged pivoted arm shown in broken lines, and in a second, expanded state 13, with the corresponding position of the hinged pivoted arm shown in solid lines.

Operative space is often increased using insufflation, wherein a gas, for example, is pumped into the operative field to thereby expand it. Insufflation is commonly used in abdominal procedures, where the relatively large abdominal chamber may safely accommodate, within a limited range, the accompanying changes in pressure. When operating in a smaller space, however, even small changes in pressure can pose risk when insufflating the operative field. Such an increase of internal pressure may occur when a gas or fluid dissection device is employed, such as the device shown in FIG. 24, in which gas or fluid is introduced into the surgical field 250 through the distal end 355 of an elongate laparoscopic instrument 350 attached to an insufflation gas or fluid conduit 360. Accordingly, the present invention optionally incorporates a safety check or pressure relief valve for use in insufflating smaller operative fields in regions like the breast.

Referring to FIGS. 25 and 26, a preferred embodiment of a seal-cap 380 according to the present invention further contemplates a pressure sensitive relief-valve 370 associated with the insufflation gas supply. A preferred insufflation pressure is maintained as dissection gas or fluid is introduced into the body cavity or operative work-space. A preferred relief-valve 370 may include an adjustable spring-loaded mechanism sized and configured to respond to low pressure and small changes in pressure that may not be recognizable to a conventional insufflation gas supply. A preferred valve protects the operative cavity from over inflation beyond the capabilities of the insufflators. The valve 370 allows gas to escape if a predetermined pressure is exceeded.

A preferred relief valve 370 may comprise a cylindrical body 371, an adjustable cap 375, a compression spring 377 and an elastomeric seal 372. A cylindrical body 371 may include a structure having a smooth sealing, first surface 373, and a fenestrated second surface 374. As the elastomeric seal member 372 is forced upward against the compression spring 377 by internal gas pressure, the fenestrated second surface 374 allows gas to escape through a plurality of openings 379 in the adjustable cap 375. When pressure is returned to an appropriate level, the compression spring 377 returns the seal member 372 to the smooth, first, sealing portion 373 of the cylindrical body 371.

A further preferred embodiment comprises a cap 375 that is axially and radially adjustable so that the preferred gas pressure may be selected or adjusted by restriction of the orifices 374 and further by compression or decompression of the internal spring 377.

With reference to FIG. 27, the present invention further comprises, in combination with circumferential retraction in a human breast, a method for illuminating a portion of tissue within a developing cavity or work-space 250. The illumination may be useful for directly visualizing the activity of a mechanical dissector. In addition to direct visualization, the illumination may be an external indicator 251 of the internal activity or the position of an illuminated instrument 300 connected to a light source 310. In a preferred embodiment, a substantially flat or spatulated dissecting instrument may be provided for use in an insufflated cavity 250. The distal end 306 of the device 300 may further comprise a plurality of lumens. A first lumen may deliver a flow of gas. A second lumen may deliver a flow of liquid or a vacuum. A third lumen may contain a fiber optic element, light emitting diode or other illuminating element.

Now referring to FIGS. 28-30, a circumferential wound retractor according to the present invention may further comprise a rigid or semi-rigid, first, circular external support member 153 connected to a cylindrical, second, connecting member 154 that is further connected to a semi-rigid, circular, third, internal support member 155. A preferred embodiment provides an illumination element or elements that are associated with the internal support member 155. A preferred illumination element may comprise a flexible fiber-optic structure, a tubular ring having a plurality of light emitting diodes, a plurality of incandescent or fluorescent light sources or the like.

In use, the internal support member 155 may be inserted through an incision in a body wall and into a body cavity 250. Once in place, the illumination elements on the internal support member 155 may be energized to produce visible light 304 to illuminate a subject field or area of interest 250. An insufflation tube 351 attached to an insufflation gas source 352 may be used to insufflate the surgical site, with the illuminating internal member provides exceptional visual presence.

A preferred embodiment of an illumination element associated with the internal support member 155 of a circumferential wound retractor may comprise a transparent or opaque flexible tubular ring 305 having a circumferential lumen. The lumen may be packed with illuminating elements. Individual Light Emitting Diodes (LEDs) 301 may comprise a preferred embodiment in a flexible or semi-flexible tubular structure 305. A flexible fiber-optic bundle may comprise an alternate embodiment. The illumination element is connected to an illumination source 303 (a light source for fiberoptic cables or an energy source for LEDs) via a connecting member 302 (a fiber optic cable or an electrical conduit for energizing LEDs). Optionally, the tubular ring includes at least a partial reflective surface configured to reflect light into the operative field 250, facilitating the use of lower intensity lights and reducing the risk of overheating.

A further embodiment of the present invention may comprise a circumferential retractor having a distal, internal support member 155 sized and configured to receive and hold an illuminating member 305. An illuminating member 305 according to this embodiment may be attachable to and removable from, the internal support member 155 associated with the circumferential retractor.

While certain embodiments have been particularly shown and described with reference to exemplary embodiments thereof, it will be understood by those of ordinary skill in the art that various changes in form and details may be made therein without departing from the spirit and scope thereof as defined by the following claims. 

What is claimed is:
 1. A surgical retractor, comprising: an external support member; an internal support member; a connecting member having a distal end, a proximal end, and a tissue contacting surface, the proximal end of the connecting member connected to the external support member and the distal end of the connecting member connected to the internal support member; a first positioning element comprising a first holding portion and a first connecting portion, wherein the first connecting portion is releasably connected to the external support member; and a second positioning element, comprising a second holding portion and a second connecting portion, wherein the second connecting portion is releasably connected to the first connecting portion, wherein the first connecting portion defines a generally semicircular configuration adapted to slide under and engage the external support member, and wherein the first connecting portion further comprising a first engaging feature and the second connecting portion further comprising a second engaging feature, wherein the first engaging feature connects to the second engaging feature when the second connecting portion is disposed over the external support structure to thereby capture the external support structure between the first and second connecting portions.
 2. The surgical retractor of claim 1, further comprising a support structure, the support structure having a base and a pivot point, wherein the base is configured to attach to a surgical table and the pivot point is configured to attach to the holding portion of at least one of the positioning elements.
 3. The surgical retractor of claim 1, further comprising a first support structure and a second support structure, each support structure having a base and a pivot point, wherein the bases are configured to attach to a surgical table, the pivot point of the first support structure is attached to the first positioning element and the pivot point of the second support structure is attached to the second positioning element.
 4. The surgical retractor of claim 1, wherein the internal support member comprises an inflatable toroid, the inflatable toroid being connected to a transfer conduit configured to interact with a gas or fluid supply.
 5. The surgical retractor of claim 1, wherein the internal support member comprises a memory foam, the internal support member configured to be deformed for insertion through an incision, returning to a predetermined shape once within the surgical field.
 6. The surgical retractor of claim 1, wherein the first engaging feature comprises detent and the second engaging feature comprises a tab.
 7. The surgical retractor of claim 1, wherein the first engaging feature comprises lattice and the second engaging feature comprises a hook. 